Heartburn & Magnesium: What's the Link?

Back in the day, in the dark ages of peptic ulcer disease, we didn't have much to offer those who suffered from heartburn and ulcers.  Heck, we didn't even know why it happened.  We put it off to stress and scoffed at the idea that an infection might increase one's risk substantially.

Then we developed H2 blockers, such as Pepcid and Zantac (not to be confused w/Xanax, a cousin of Valium, the addicting anti-anxiety drug).  At first, like most drugs, these were only available by prescription only.  However, they soon made over-the-counter.  But these medications weren't completely successful.

So we then developed the proton-pump-inhibitor class, a revolution in stomach acid control.  Who doesn't know of the purple pill (not to be confused with the blue pill used for a completely unrelated purpose) that brought relief to so many sufferers.  Similarly, this drug was originally only available by prescription.  But over the last several years, half-strength versions have made it over-the-counter.

And therein lies the problem.  Because these medications are so efficacious in controlling heartburn symptoms and because they are so easily obtained these days, many patients are taking them without medical supervision.  Of course, no one remembers to tell their family physician about all those pesky over-the-counter medications and herbal supplements that they're taking, especially the natural & organic ones since they must be good for you, right?

Well, we've recently learned, to the contrary, that we do have to be concerned about long-term use of PPIs.  For instance, PPIs have been associated with osteoporotic fractures because they make it difficult to absorb calcium carbonate, the most common form of calcium supplement, due to their acid suppressing properties.  More recently, PPI use has been associated with an increase risk of pneumonia, both in the community and in the hospital, whether on the ward or postoperatively.  Worse, PPI use has recently been linked to an increase risk of dangerous diarrhea due to Clostridium difficile.  And, PPI use has also been linked to higher risk of recurrent heart attacks due despite the use of anti-platelet drugs such as clpidogrel & prasugrel.

With all that background, guess what?  In an announcement yesterday from the FDA, PPIs were declared to decrease magnesium absorption to such a degree that long term use can cause hypomagnesemia (low magnesium) leading to muscle spasm (tetany), irregular heartbeat (dysrhythmia), and convulsions (seizures), of which the latter two can result in death.

So we've just been warned to check magnesium levels prior to starting PPIs in those expected to be taking this for a long period of time (more than 1 year).  We should also check magnesium in those who are also taking digoxin, diuretics (water pills), and any other drugs that can, in and of themselves, cause low magnesium, prior to starting PPIs.  

In 2009, 21 million patients obtained prescription-strength PPIs and took them for an average of 6 months, whereas prolonged period of time is considered more than a year.  Compare that to the millions of patients who take OTC PPIs without supervision.  It's doubtful that they stop after 14 days and don't repeat more than 2 times (3 total) each year.  After all, if it works and the heartburn is gone, why stop?  Especially if it comes back again?  Plus it's cheaper to take this OTC medication than to seek medical attention.  And there's no time loss waiting in the doctor's office reading months old magazines.

My point is this.  Whether you're taking a prescription PPI, eg Aciphex, Dexilant, Nexium, Prevacid, Prilosec, or Zegerid, or an OTC PPI, eg Prevacid 24HR, Prilosec OTC, or Zegerid OTC, ask your family physician to consider checking your magnesium level.  And by the way, consider switching from calcium carbonate to calcium citrate.